infant feeding and nutrition dr janet anderson. infant nutrition good nutrition is essential for...
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Infant feeding and nutrition
Dr Janet Anderson
Infant Nutrition
Good nutrition is essential for
• Survival
• Physical growth
• Mental development
• Productivity
• Health and well being
-----across the whole life span
What we know
• Good early nutrition has profound effects on long term health, by programming aspects of subsequent cognitive function, obesity, cardiovascular risk, cancer and atopy.
• But what is optimal early nutrition?
Early Programmming
• Babies who are small for gestational age at birth or who are light for height at one year are more likely to have cardiovascular disease, hypertension, type 2 diabetes and/or hypercholesterolemia particularly if they are forced to gain weight after this time.
Infant feeding
• Until the latter part of the 19th century infant survival was dependent on breast feeding
• Wet nurses were frequently used if mother could not produce enough milk.
• Although infant feeding bottles were found in the artifacts of Pharaohs it wasn’t until the 20th century that artificial milks were developed and after considerable research became nutritionally acceptable
19th and 20th Century feeding bottles
Nutritional requirements
Age dependent The younger the child the higher their
energy needs per kilogram body weight 0-3 months Fluid100-150mls/kg Calories 100kCals/kg Protein 2.1g/kg Na 1.5mmol/l K 3mmol/l
Breast Feeding
• It is the baby’s demand that regulates the supply of breast milk not necessarily lactation supply
• The let down reflex can be delayed in some mother’s leading to frustration .
• Any practice that limits milk output in the first week of life may limit milk output in the long term
• Ad libitum breast feeding is associated with improved outcomes
Colostrum
• Contains more sodium
• High in Vit A and Vit K
• Contains 5x more protein than mature milk
• Contains more IgA
Advantages of breast feeding• Appropriate bonding and psycho social development• Reduced morbidity (-- NEC less in preterm breast fed
babies)• Better nutritive balance– minerals are more easily
absorbed• IgA, lactoferrin and lysozyme reduce infection—
particularly gut and ears• Human milk contains a growth factor for Lactobacillus
bifidus which increases acidity in the gut to inhibit growth of pathogens
• Immune response to Hib vaccine higher• Reduces the risk of obesity
Down sides of breast feeding
• Vitamin K deficiency• Hypernatraemia at end of first week in babies
with inadequate intake.• Inhibits modern control culture!• No good evidence that reduces colic
• Breast feeding alone beyond 6 months may lead to anaemia and Vit D deficiency therefore wean and add vitamin supplements
Breast feeding and obesity prevention
Artificially fed babies consume 30,000 more calories than breastfed infants by 8 months of age Riordan et al. 1999
Breast feeding and ObesityEpidemiological evidence suggests that breast feeding
represents an ideal opportunity for obesity prevention.Breast milk could influence the development of taste receptor
profile which fosters a preference for lower energy diets later on in life
Breast fed learn to regulate their appetites by stopping when they are full. Fore milk satiates thirst, hind milk hunger.
Breastfed babies have lower levels of insulin, a hormone that promotes the storage of fat.
The link between breast feeding and obesity appears to be greatest after infancy- in the 9-14s
Leptin, an anorexiogenic hormone, in breast milk may also play a part
Long term benefits of breast feeding
Compelling evidence that reduces
Cardiovascular disease
Obesity
Improves cognitive development
Reduces atopy but not in all
More controversial
Reduces IDDM,--(recent trials to determine whether BF is protective), neoplastic disease, osteoporosis and inflammatory bowel disease
Contraindications to breast feeding
• Maternal drugs including anti-metabolites, opiates, amiodarone,
phenindione ----others but mostly relative not absolute
• Maternal HIV in the developed world; still controversial in resource poor countries
• Note:---Babies of mothers with TB can be immunised at birth with BCG and treated with Isoniazid for 6 weeks and still be breast fed
Artificial feeds
• Introduced in 1907 by Rotch in U.S.• Nutritionally complete• Contain more Vit. K ,Iron ( but less available)
and Calcium and Vit. D than breast milk • Whey based or casein based• Soya milk no longer recommended for under 6
months (probably better after one year)• Has caused high mortality in developing world
due to poor hygiene of equipment leading to gastroenteritis
• Must be made up correctly
1950’s Royal Formula
Types of artificial formula
• Whey based• Casein based• Lactose free/partially lactose
free (Omneocomfort)• AR• Follow on milks• Organic milks• Low allergenic milks• Specialist milks i.e.
phenylalanine free• Soya milk• Goats milk
Pre-term formulas
• Developed in 1980s
• Contain more electrolytes
calories
minerals
• Long-chain polyunsaturated fatty acids plus pre-biotics added 2000s
Questions?
• How many calories in 100ml of breast milk?
A. 65-70kCals (depends whether fore or hind milk)
• How many calories in ordinary formula?A. 70kCals/100ml• How many calories does a baby need to
grow normally in the first 3 months?A. 100kCals/kg
Cow’s milk allergy
Clinical features include Gastrointestinal---colic vomiting diarrhoea colitis Rashes including eczema and urticaria Respiratory—rhinitis stridor cough and wheeze Irritability Failure to thrive etc
Diagnosis of CMP allergy
• Formal allergy tests may not help.• Rast test may be negative• Skin testing is better• Colonoscopy may be necessary in colitis • Best is to remove cow’s milk protein from
diet and watch• Do not confuse with lactose intolerance
Lactose intolerance
• Primary lactose intolerance rare• Usually secondary to gastrointestinal
infection especially rotavirus ,or neonatal gut surgery
• Explosive fermentative diarrhoea• Stool Clinitest > 0.5% / sugar
chromatography of stool• Usually transient but may need to remove
lactose from milk for 6+ weeks
Weaning
• Latest government recommendations suggest 6 months.
• Some controversy about this a hard and fast rule
- not before 17 wks and not later than 26wks• Babies need to be exposed rapidly to a variety of
tastes and textures between 6-8 months if weaning is delayed otherwise taste preferences will be limited
• Vegetables and fruits are ideal weaning foods• Encourage finger feeding because they can pick up
food and are unlikely to choke.
Weaning• Breast fed babies run low on iron and calcium
if not weaned at 6 months and this may occur before this time
• They are often perceived to be signaling hunger before 6months
• Only 1-2% of a cohort of British breast feeding mothers delayed weaning until 6 months
• ESPGAN suggest weaning 17-26 weeks –no earler, no later
Baby-led feeding
• Allows babies to feed themselves
• No spoon feeding and no purees
• Only the baby feeds themselves.
• Starts at 6 months when baby can sit upright, able to pick up pieces of food and chew them
• Expect a mess.
• Keep it enjoyable-sits with family to eat.
Weaning
If breast feeding continued exclusively for too long i.e.> 4/5 months, this is associated with
1.Iron deficiency with its associated adverse developmental outcomes
2.Calcium/ Vit D deficiency
3.Other possible effects –allergy , coeliac disease and obesity?
Vitamins
• All children from 6 months onwards should be given supplements that contain vitamins A,C and D –such as Healthy Start vitamins unless they are drinking more than 500mls of formula.
• If mothers did not take vit. D during pregnancy and if breast fed, start Vit. D at 1 month
Allergy and Coeliac Disease• Rising rates of allergy despite increasing
advice to delay exposure to potentially allergenic foods.
• Where peanuts are used as weaning foods, lower incidence of peanut allergy
Critical window of exposure?• 2008 review suggested increased risk if
solids introduced before 3 /4 months• Gluten exposure best between 3 and 6
months along side breast feeding?
Failure to thrive
• Definition: growth or weight faltering - Weight and/or height below 2nd centile; Crossing down 2 centile channels for height and
weight • Most due to non organic failure to thrive• Organic causes related to feeding difficulties because of
anatomical defects or chronic illness eg heart disease• Food intolerance including coeliac disease• Neurological problems
Factors in the history
• Consider factors that interfere with sucking and intake
• Conditions that interfere with absorption e.g. intestinal resection, coeliac disease
• Conditions that increase losses e.g. diarrhoea, vomiting
• Increased needs e.g. fever, sepsis, tissue injury, heart failure
• Conditions that restrict intake e.g.food intolerance, renal disease, heart disease
• Other gastrointestinal pathology.
Non-organic failure to thrive
• Maternal depression/psychiatric disorder
• Disturbed maternal-infant attachment
• Eating difficulties
• Neglect
Nutritional assessment
• Take a careful history
• Assess intake
• Consider requirements
• Weigh
• Children with chronic illness should have a detailed assessment
Clinical pointers in failure to thrive
• Differentiate from the normal baby who is crossing the centiles
• Identify any symptoms and signs that suggest an organic condition
• Only perform investigations if there are clinical leads
• Identify psychosocial problems that might be affecting the baby’s growth
Consequences of poor weight gain in infancy
• 5-20 points in IQ
• Increased cardiovascular risks, hypertension, hypercholesterolaemia and Type 2 diabetes
Obesity
• Increasing morbidity• Prevention is required• Increased risk of early Type 2 diabetes, fatty
liver, sleep apnoea, poor school performance, SUFE, etc
• 25% children at risk• Note –an individual’s response to a high calorie
diet is subject to strong genetic influence
A world of difference
Constipation in the first year of life
Common causes Over diagnosed in breast fed babies Incorrect making up of formula feeds Changing from whey based to casein based
feeds Weaning Over dependence on milk as nutrition in older
babies Potty training